An updated version of the American Academy of Pediatrics’ Recommendations for Preventive Pediatric Health Care, published in the January 2016 issue of Pediatrics, includes screening recommendations that may still be slow on the uptake in pediatric practices since being approved by the AAP 2 years ago.
Depression screening is “starting to improve,” but lipid screening and HIV screening have been “harder to implement,” said Dr. Geoffrey R. Simon, chair of the AAP’s Committee on Practice and Ambulatory Medicine, which works with the Bright Futures Periodicity Schedule Workgroup to keep the schedule up to date.
Joseph F. Hagan Jr.
Publication of the schedule in Pediatrics (2016 Jan. doi: 10.1542/peds.2015-3908), as has been done every 3-5 years, is in many ways a formality this time around. Two years ago, the AAP began updating the schedule in real time to immediately reflect new recommendations and guidelines endorsed or produced by the Academy for comprehensive health supervision.
“The goal has been to shorten the time frame for incorporating new evidence, including removing screening items that research has demonstrated aren’t useful,” Dr. Simon, a pediatrician in Wilmington, Del., said in an interview.
Each of these screenings, however, like the other recommended services listed in the Periodicity Schedule, is backed by evidence and is required under the Affordable Care Act to be covered by insurers without any cost sharing. Other recommendations include a call for fluoride varnish applications from 6 months through 5 years.
“These aren’t just good ideas. There is strong evidence for [every recommendation] on the Periodicity Schedule,” Dr. Joseph F. Hagan Jr., a member of the Bright Futures Periodicity Schedule Workgroup and a pediatrician in Burlington, Vt., said in an interview.
The updated schedule no longer recommends vision screening at age 18 years, based on evidence showing that far fewer new vision problems develop in low-risk young adults as younger children. It also omits routine screening for cervical dysplasia until age 21 years.
The change from vision screening to risk-based assessment at age 18 coincides with publication – also in the January issue of Pediatrics – of an AAP policy statement on Visual System Assessment in Infants, Children, and Young Adults (Pediatrics. 2016 Jan. doi: 10.1542/peds.2015-35970.) and an accompanying clinical report titled Procedures for the Evaluation of the Visual System by Pediatricians (Pediatrics. 2016 Jan. doi: 10.1542/peds.2015-3597).
Screening for depression is recommended annually from ages 11-21 years, as suicide is now a leading cause of death among adolescents. And HIV screening is recommended for adolescents aged 16-18 years to address federal statistics showing that 1 in 4 new HIV infections occurs in youth aged 13-24 years, and that about 60% of all youth with HIV do not know they are infected, according to the AAP.
The recommendation for dyslipidemia screening covers patients aged 9-11 years, in addition to those aged 18-21 years. The recommendation to screen once during each of these two windows of times is based on guidelines from the National Heart, Lung, and Blood Institute on cardiovascular risk reduction in childhood and adolescence, Dr. Simon said.
“It was an attempt to make it easier and more effective by replacing an ineffective and cumbersome two-step screening process using risk assessment with lab testing if needed,” he said.
At the annual meeting of the AAP in October 2015, pediatric cardiologist Dr. Sarah de Ferranti said in a packed sessionon lipid screening that getting a family history of cardiovascular disease has proven unreliable for identifying children at high risk of disease – even those with familial hypercholesterolemia. This disorder affects 1 in 250 individuals, she said, and is usually “asymptomatic until individuals present in their young adulthood with a much higher risk of heart disease … or until they come to the ER as adults.”
Dr. Karalyn Kinsella
Dr. Karalyn Kinsella, a pediatrician in Cheshire, Conn., is among those pediatricians who have found lipid screening and HIV screening to be particularly challenging. “The difficulty [with lipid screening in my practice] is with those children who are already physically active, have healthy diets, and a normal BMI,” said Dr. Kinsella, who was asked to comment on the current periodicity schedule. “When they have elevated lipid levels, what is our next step? For those not high enough to treat, it can create unnecessary anxiety in families.”
With respect to HIV screening, payment issues can impede confidentiality. “We’re obligated to maintain confidentiality with the teen, but parents sometimes see the bill,” she said, adding that many her adolescents’ families “have health savings accounts with high deductibles and have to pay out of pocket.”